Evoke Wellness and Health Forms Packet Wellness and Health Coach: Sandra LaBella, PT, CWHC Date:

Laying the Foundation for Coaching

As your coach, it’s important for me to understand how you view the world, yourself, and your job or career. Each person is unique and understanding you will help me support and assist you.

Answering these questions clearly and thoughtfully, will serve both you and me. You may find that they help you clarify perceptions about yourself and the direction of your life. These are “pondering” type questions, designed to stimulate your thinking in a way that will make our work together more productive. Take your time answering them. If they are not complete by our first (foundation) session, just bring what you have completed and finish the rest later. These answers will be treated with complete professional confidentiality.

What do want to get from the coaching relationship?

What is the “best” way for me to coach you most effectively, what tips would you give to me about what would work best?

Do you have any apprehension or pre-conceived ideas about coaching?

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What are 3 things you would like to me to know about you?

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2.

3.

Personal

1. What accomplishments or events must, in your opinion, occur during your lifetime to consider your life satisfying and well lived?

2. What is (or might there be) a secret passion in your life? Something you may or may not have allowed yourself to do so far, but which you would really love to do.

3. What unique gift or knowledge do you have to contribute?

4. Please describe what gives you a sense of purpose in life? What activities have meaning for you?

5. What’s missing in your life, the presence of which would make your life be more fulfilling?

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6. What do you do when you are really up against the wall?

Health & Wellness Information As your coach, my job is not to “treat” you, but to be your ally and your resource. When it comes to health and wellness issues I will help you discover steps you may choose to take towards greater health and higher levels of wellness.

As your ally, I may refer you to medical, psychological, nutritional and other health-related services for more information and to seek any treatment in these areas. I can be a source of support and accountability, helping you to follow through with any treatment plans that you devise with these other professionals.

Please share with me information about your health and wellness so that I may more fully understand your health challenges and aspirations for higher levels of wellness.

1. Please describe your lifestyle and what you do to be healthy and well.

2. Please describe any health challenges that you currently experience (major concerns as well as just bothersome things like headaches, insomnia, etc.)

3. Are you currently on any medications? If so what is the name of the medication and the intended impact of the medication?

4. What do you do to reduce stress in your life, or to counter-act the effect of stress in your life?

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5. Please describe a typical week in terms of diet and exercise/activity.

6. What do you do in your life that brings you happiness and joy? How often do you do this?

7. What gets in the way of you doing what brings you joy and health in the world?

8. How can a coach be of assistance in helping you make the lifestyle changes you’d like to make?

9. What two steps could you take immediately that would make the greatest difference in your current situation?

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GENERAL INTAKE FORM

I. General Information Section: First Name ______Last Name ______Middle Initial ___ Address ______

DOB _____/_____/_____ Age _____ ⃝ Married ⃝ Single ⃝ Divorced Occupation ______Email ______Home Phone ______Cell Phone ______Work Phone ______Emergency Contact ______Phone ______Family Doctor ______Phone ______Address ______Insurance ______Who May We Thank For Referring You? ______

II. Goal Section:

⃝ I am seeking wellness services for one of the following: Reiki, Health Coaching and or Craniosacral.

⃝ My Goals are ______

Please Note: Reiki does not take the place of medical care. It is recommended that you see a licensed physician or health care professional for any pain, physical or psychological aliment you may have.

III. Current Medical History ⃝ Do You Have Any Current Concerns Or Complaints? ⃝ Yes ⃝ No If yes, please describe: ______

Do You Have Any Pain?

Are You Under The Care Of A Physician For Any Medical Condition? ⃝ Yes ⃝ No If Yes, Please Describe: ______

Are You Receiving Any Other Services Or Treatments? ⃝ Yes ⃝ No If Yes, Please Describe: ______IV. Medications /Vitamins/Dietary Supplements: ______V. Allergies: ______VI. Past Surgical History: Please List and Date All Surgeries ______VII. Recent Medical Complaints: Please Check All That Apply To You ⃝ Black Tarry Stools ⃝ Chest Pain ⃝ Coughing Up Blood ⃝ Unexplained Weight Loss ⃝ Blood in Stool ⃝ Excessive Fatigue ⃝ Blurred Vision ⃝ Night Sweats ⃝ Blood in Urine ⃝ Shortness of Breath ⃝ Continuous Diarrhea ⃝ Doctor Notified ⃝ Yes ⃝ No

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GENERAL INTAKE FORM

VIII. Past Medical History: Please Check All That Apply To You ⃝ High/Low Blood Pressure ⃝ Chronic Fatigue ⃝ Constipation ⃝ Heart Conditions ⃝ Fibromyalgia ⃝ Irritable Bowel Syndrome ⃝ Pacemaker ⃝ Multiple Sclerosis ⃝ Incontinence ⃝ Diabetes ⃝ Depression ⃝ Bladder Problems ⃝ High Cholesterol ⃝ ⃝ Bowel Problems ⃝ Cancer ⃝ Osteoporosis ⃝ Kidney Disease ⃝ Chemotherapy/Radiation ⃝ Prostate Problems ⃝ Sexual/Physical Abuse ⃝ Anemia ⃝ Back Pain ⃝ Sexually Transmitted Disease ⃝ Bleeding Disorder ⃝ Numbness/Tingling ⃝ Liver Disease ⃝ Blood Clot/Embolism ⃝ Pelvic Pain ⃝ Hepatitis ⃝ Cerebral Hemorrhage/Stroke ⃝ TMJ Pain ⃝ Alcoholism | Drug Problem ⃝ Head Injury/Recent Skull Fracture ⃝ Sports Injuries ⃝ Smoking History ⃝ Acute Aneurysm ⃝ Arthritis ⃝ Vison Loss | Problems ⃝ Headaches ⃝ Joint Replacement ⃝ Life Threatening Allergies ⃝ Seizures/Epilepsy/Convulsions ⃝ Pins or Metal Implants ⃝ Latex Allergy ⃝ Asthma ⃝ Fractures ⃝ Allergy: Coconut |Beeswax |Perfume ⃝ Emphysema ⃝ Hypothyroid/Hyperthyroid ⃝ Trouble Sleeping ⃝ Acid Reflux/Belching ⃝ Hyperglycemia/Hypoglycemia ⃝ Hearing Loss ⃝ Anorexia/Bulimia ⃝ Dizziness/Fainting ⃝ Currently Pregnant ⃝ Other ______⃝ Other ______⃝ Other ______

IX. Acknowledgement of Receipt of Notice of Privacy Practices: SIGNATURE: I, ______, acknowledge that I have received the Notice Of Privacy Practices for Evoke Physical Therapy and Wellness Center, Inc. I have had full opportunity to read or have had read to me and consider the contents. I Consent to use and disclosure of your Notice of Privacy Practices.

X. Privacy Authorization: Your Rights: When it comes to your protected health information you have the right to request confidential communications or that communication be made by alternative means. You may contact: ⃝ Cell ⃝ Home ⃝ Work. Leave Message ⃝ With Family ⃝ Voice Mail ⃝ Text ⃝ Email We are happy to include you in our Email Newsletter, Special Events & Educational Lectures. Please let us know if you do not wish to subscribe. ⃝ Yes Include Me ⃝ No, I Do Not Wish To Subscribe Email and Text Messaging is a NON-SECURE Network and Confidentiality Cannot be Guaranteed.

XI. Electronic Payment Communications: We accept cash, check or credit. It is your right to pay for fees electronically, using a credit or debit card. The financial services company we use is Square. For more info see: www.squareup.com. In order to utilize Square and maintain HIPPA Regulations, we must limit our activities to only normal financial transaction services. What this means is we cannot offer you the automatic receipt or text receipt services that are normally offered by square. We have turned this automatic function off and can provide you with a receipt. Although we provide reasonable means to protect your privacy, please consider the associated risks of electronic payment communications. ⃝ I wish to pay for services with my Credit/Debit Card. I consent to electronic payment communication.

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GENERAL OFFICE POLICY We are dedicated to providing you quality care and service. In an effort to maintain high standards and fairness to all of our clients we ask for your cooperation and consent to the following office policies: Lateness: Please come to your appointment on time or phone in at your appointment time for consideration to those following your session. We are understanding of the occasional unanticipated events and will provide accommodations as best we can. However, we will not provide accommodations for consistent lateness and you will be responsible for the full session charge and your reserved treatment time will end as scheduled. Cancellations: If you need to cancel your appointment, you must notify us 24 hours prior to your schedule appointment time. Cancellations less than 24 hours will be charged half your reserved session cost payable prior to your next scheduled appointment. We are accepting of the occasional unanticipated events including family emergency, illness & severe weather. No-show: If you fail to attend your reserved treatment time, you will be charged half your reserved session cost payable prior to your next scheduled appointment. Payments: All payments are due at the time of service. We accept cash, credit and checks. You will be given a receipt for services rendered. Non-sufficient funds, canceled checks or returned checks will be subject to a $25 dollar charge due prior to the next scheduled appointment. In the event you fail to pay your bill, by signing below you are agreeing to pay in addition to the amount of the bill, any reasonable attorney’s or collection fees to the provider. A photocopy of this authorization form shall be considered as valid as the original. Insurance: We are a fee for service practice and do not accept any private insurance. It is your responsibility to call your insurance to verify your reimbursement coverage for the services we provide. We are happy to assist you in any way we can. If your insurance requires additional information please let us know how we can help. If you would like some additional assistance on how to verify your coverage, please let us know; we have available a sample insurance verification questionnaire which may assist you further. Medicare: Medicare covers 80% of Medicare’s fee schedule. If you do not have supplemental insurance or supplemental with out of network coverage, you are responsible for the remaining 20%. You are responsible for your annual Medicare deductible. Medicare has cap on the allowable physical therapy and speech therapy combined services of $1960 per year. There are exceptions to Medicare’s Cap that you may qualify for which can extend your services for physical therapy. However, if you do not qualify and services are not medically necessary but you wish to continue Physical Therapy, you will be given an Advance Beneficiary Notice of Non-coverage (ABN) to sign. In the event that Medicare denies coverage at that point, you will be responsible for payment. Self-Care and Wellness: Most insurance companies do not reimburse for Reiki or Wellness and Health Coaching. Most insurance companies do not reimburse for any non-injury or non-condition related physical therapy service such as learning exercises to stay in shape or receiving an enjoyable craniosacral treatment. It is your responsibility to verify this information and your benefit coverage with your insurance company. Termination Rights: You have the right to terminate your care at any time. Evoke Physical Therapy and Wellness Center, LLC has the right to terminate your care if we feel your needs are best met at another practice. Evoke Physical Therapy and Wellness Center, LLC has the right to terminate your care immediately with any verbal or physical threat or abuse of any kind. Office Space: This office is not a group practice. Evoke Physical Therapy and Wellness Center, LLC is an individual practice located within this office location. Informed Consent: I have read or had read to me this form and had any questions answered to my satisfaction. I fully understand and agree to Evoke Physical Therapy and Wellness Center office policy and my financial responsibility to pay for services rendered and charges incurred for cancelations or no-shows. I understand that it is my responsibility to call my insurance to verify coverage and reimbursement if any. If I am a Medicare beneficiary, I understand my responsibility regarding my copayment and deductible; I understand that Medicare does not cover medically unnecessary services. However, if I choose to receive wellness and personal lifestyle services that by signing an ABN form, I am agreeing to pay for non-covered services. I understand the termination of care rights as written above. I understand that I am a client/patient of Sandra LaBella, PT, CWHC of Evoke Physical Therapy and Wellness Center, LLC located within this facility. I understand this is not a group practice and the care and services I receive from Sandra LaBella, PT, CWHC are exclusive to Evoke Physical Therapy and Wellness Center, LLC and not of any other practitioner at this same location. I understand that it is my right to obtain services at this same location from other practitioners; If I choose to do so, I agree to hold Sandra LaBella, PT, CWHC harmless for any and all actions, damages or injuries both to my person and to my property which have resulted or in the future may develop or arise out of services obtained from other practitioners at this same location. By signing this form, I am agreeing to the above.

Print Name ______Signature: ______Date: ______

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COACHING CLIENT AGREEMENT AND DISCLOSURE STATEMENT AS REQUIRED UNDER SB-215 FOR COMPLEMENTARY AND ALTERNATIVE HEALTH CARE PRACTITIONERS IN COLORADO

1. Name: Sandra LaBella, PT, CWHC Phone: 303475-6252 2. Office Name: Evoke Physical Therapy and Wellness Center, LLC 3. Location 1: 2305 E Arapahoe Road, Suite 227, Centennial CO, 80122 4. Location 2: 10989 Sundial Rim Road, Highlands Ranch, CO 80126 As a Complementary and Alternative HealthCare Practitioner, I am not licensed, certified or registered by the state of Colorado as a health care professional. I am not a licensed medical physician and do not diagnose, treat or prescribe remedies for the treatment of disease. The services I perform, whether in person, by mail or by phone, are at all times restricted to complementary and alternative health care services. I am prohibited from performing surgery or any invasive procedure, administer or prescribe x-ray radiation, prescribe prescription drugs, use general or spinal anesthetics, administer ionizing radioactive substances, use a laser device that punctures the skin, perform enemas/colonics unless board certified, practice midwifery, practice , perform spinal manipulation, practice optometry, directly administer medical protocols to a pregnant woman or a person who has cancer, practice dentistry, set fractures, practice massage therapy, provide a conventional medical disease diagnosis or recommend the discontinuation of a course of care recommended by a health care professional. I am also prohibited from treating children less than two years of age. In order to treat a child who is between 2-8 years of age, I must have a written, signed consent of the child’s parent or legal guardian. Complementary & Alternative Health Services provided at Evoke Physical Therapy & Wellness Center, LLC include Reiki and Wellness & Health Coaching. The nature of the Complementary & Alternative Services for Coaching is: Wellness and Health Coaching: As a Wellness and Health Coach we support and guide you in reaching your goals and well life vision. Our job is to explore the lifestyle changes you want, facilitate a process of change and help you develop the tools you need, self-efficacy and internal motivation towards actualizing yours dreams. The coaching services are designed jointly with the client; together we will engage in direct and personal conversations. The client can count on the coach to be honest and straightforward in asking questions and making requests towards your goals. The coach relationship is professional and strictly confidential. Wellness Mapping 360°© is the model we use for our Coaching Services. Typical sessions are 30 or 60 minutes located in our office or phone. My professional degrees, training, experience, credentials and qualifications are as follows: Wellness and Health Coach: Certification: Wellness and Health Coach, 2015; Training: Wellness Mapping 360° Wellness & Health Coach Certification Training; Real Balance Global Wellness Services Inc., Fort Collins, Colorado Physical Therapy: * please note the above disclosure statement and prohibitions of practice is a requirement for my practice of Reiki and Wellness and Health Coaching as a complementary and alternative health care practitioner in the state of Colorado. These services are separate from my practice of physical therapy. As a State Licensed Physical Therapist, the practice of physical therapy and related treatment techniques and modalities is within the scope of my practice as a physical therapist. Therefore any prohibitions listed above for the practice of Reiki or Wellness and Health Coaching as a complementary and alternative health care practitioner do not apply to my practice of physical therapy. State Licensed Physical Therapist, 1997 to date; Colorado License Number: TL.0012994 New York License Number: 017303; Bachelor of Science in Physical Therapy May 1997; State University of New York at Buffalo, Buffalo, New York Reiki: Certification: Reiki Master, 2015; Training: Usui Shiki Ryoho Reiki Training 1st, 2nd and 3rd degree; Body Mind Energy Center, Denver, CO: Master Teacher, Reece Leonetti, MA Potential Benefits: Coaching provides support towards reaching your goals and well life vision. Potential Risks: As a coach we provide support towards reaching your goals and well life vision. You are fully responsible for your well-being during coaching including the choices and decisions you make towards your goals. Coaching should not be used to replace medical care. It is your responsibility to maintain a relationship with your doctor and seek treatment from a health care physician if you have a health problem. No Guarantees: No one can predict with certainty the results of the services provided. We do not offer guarantees concerning outcomes or promise specific results or outcomes. Alternatives: If you are uncomfortable with anything during your session at ANY TIME, please inform the provider immediately and your concerns will be discussed with you. As your coach we are 100% committed to you being successful in having the life you want. If appropriate, we will refer you to an appropriate health care professional. Liability Insurance: Evoke Physical Therapy and Wellness Center, LLC carries liability insurance applicable to any injury caused by an act or omission in providing complementary and alternative health care services.

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COACHING CLIENT AGREEMENT AND DISCLOSURE STATEMENT File Records: You will be provided with a copy of this disclosure statement and the original disclosure statement copy will be kept on file for at least two years after the last date of service.

Recommendations: As my client, you should discuss any recommendations I provide with your Primary Care Physician, Obstetrician, Gynecologist, Oncologist, Cardiologist, Pediatrician, Pediatric Health Care Provider, or other Board-Certified Physician. Termination Rights: You have the right to terminate your care at any time. I have the right to terminate your care if I feel your needs would be best met at another practice or referral to a medical professional is necessary. I have the right to terminate your care immediately with any verbal or physical threat or abuse of any kind. Informed Consent: The term “informed consent” means that the potential risks, benefits and alternatives of our services have been explained to you. By signing below you are voluntarily consenting to our services and acknowledging receipt of our disclosure statement in accordance to Colorado State Law SB-215:  I have read or had read to me the above disclosure statement in accordance to Colorado State Law SB 215 and have been provided with a copy for my records. I understand the nature of the Complementary and Alternative Health Care services to be provided and had any questions answered to my satisfaction.  I understand that Wellness and Health Coaching, a Complementary and Alternative Health Care Service, is not a licensed, certified or registered profession with the State of Colorado.  I understand the risks, benefits and alternatives to the coaching services provided. I understand that I am not being given a guarantee or being promised a specific result or outcome.  I understand that Health and Wellness coaching is a comprehensive process that may involve all areas of my life, including work, finances, health, relationships, educations and recreation. I acknowledge that deciding how to handle these issues and implement my choices is exclusively my responsibility.  I understand wellness and health coaching is a relationship I have with my coach that is designed to facilitate the development of personal, professional, and/or business goals and to develop and carry out a strategy/plan for achieving those goals.  I understand that I am fully responsible for my well-being during my coaching session, including my choices and decisions. I understand that if I am uncomfortable at any time during a session, I will inform the provider immediately and my concerns and alternatives will be discussed with me. I am aware that I can choose to discontinue coaching at any time and that professional referrals will be given if necessary.  I understand it is my responsibility to maintain a relationship for myself and/or my child with a medical doctor. I understand these services are not intended to replace any medical services prescribed by my doctor  I understand that Health and Wellness coaching does not treat mental disorders as described by the American Psychiatric Association. I understand that coaching is not a substitute for counseling, psychotherapy, psychoanalysis, mental health care or substance abuse treatment, and I will not use it in place of any form of therapy. I promise that if I am currently in therapy or otherwise under the care of a mental health professional, that I have consulted with this person regarding the advisability of working with a Health and Wellness coach and that this person is aware my decision to proceed with the coaching services.  I understand that wellness coaching is not to be used in lieu of professional advice. I will seek professional guidance for legal, medical, financial, business, spiritual, or other matters. I understand that all decisions in these areas are exclusively mine, and I acknowledge that my decisions and actions are my responsibility.  I understand that information will be held as confidential unless I state otherwise, in writing, except as required by law. I understand that certain topics may be anonymously shared with other wellness coaching professionals for training or consultation purposes. I voluntarily consent to Wellness and Health Coaching, the Complementary and Alternative health Care services that I have obtained through Evoke Physical Therapy and Wellness Center, LLC for myself and/or my child.

Client Name ______Client/Guardian Signature______

Child Name (Age 2-8) ______Signature Parent/Guardian ______

Today’s Date ______Date of Birth ______

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